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Substance Abuse

Terms in this set (82)

Define substance abuse
Maladaptive pattern of substance use leading to clinically significant impairment or distress
Define addiction
Primary, chronic, neurological disease with genetic, psychosocial, and environmental factors influencing its development and manifestations, characterized by the following behaviors ("the 5 C's)
1.) Chronicity
2.) Control over drug abuse
3.) Compulsive use
4.) Continued use despite harm
5.) Craving
What are the different factors that affect the degree of substance abuse?
The type of substance abused
The Individual
The Environment
How might the type of substance being abused factor into the degree of substance abuse?
Reinforcing qualities (pleasure, euphoria)
Cost
Accessibility
Purity
Mode of administration
Speed of onset
How does the individual factor in to the degree of substance abuse?
Heredity
Prior experience
Risk taking behavior
Psychiatric influences
Self-esteem
Rebelliousness
Poor coping skills
Poor acceptance of responsibility for actions
How might the environment a person is in factor into the degree of substance abuse?
Social setting
Community attitudes
Peer influences
Role models
Lack of other pleasurable alternatives
Socio-economic issues
Define physical dependence
State of adaptation that is manifested by drug class-specific withdrawal syndrome
Rate of development of physical dependence is a function of...
Sufficient amount of drug at the site of action
Sufficient period of exposure
Sufficient consistency of drug exposure
Define cross-dependence of a drug
Ability of a second drug of the same class (similar mechanism of action) to maintain the dependence of an original drug
Define psychological dependence on a drug
Subjective need or compulsion to use the drug in order to maintain a feeling of well being

May be present even in the absence of physical dependence
When assessing drug abuse, what is "loss of control"?
Is the patient in control of their life or is the pursuit of and continued use of a substance in control?
What is the questionnaire used to evaluate substance abuse?
CAGE questionnaire
C: Have you ever felt you ought to Cut down on your drinking?
A: Have people Annoyed you by criticizing your drinking?
G: Have you ever felt badly or Guilty about your drinking
E: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye opener)?
What is abstinence syndrome?
A group of physiologically abnormal signs and symptoms which occur upon cessation
Rate of development in abstinence syndrome is a function of...
Half-life of the drug at site of action
Receptor blockade (antagonist)
How do you treat withdrawal syndrome?
-Determine if pharmacological treatment of withdrawal symptoms is necessary (Always yes for alcohol and depressants where withdrawal is life threatening)
-Manage the major symptoms of withdrawal like hypertension, seizures, arthralgias and nausea
-Refer patient to appropriate substance abuse treatment program
What is the pathophysiology of addiction?
All abused substances appear to activate the same reward pathway with dopamine as the final common neurotransmitter

Mesolimbic and mesocortical pathways (VTA to Nucleus accumbens, amygdala and hippocampus, and prefrontal cortex)
What are the intoxication signs and symptoms?
Euphoria is common
Define sensitization
Increased response to repeated and intermittent administration of the drug
Define drug counteradaptation (tolerance)
The initial reward experience results in tolerance to the reward that requires more drug be used to recreate the reward experience
Define drug tolerance
State of adaptation in which exposure to a drug induces changes that result in a reduction of one of more of the drugs effects over time
What are the different types of drug tolerance?
Pharmacokinetic tolerance - organ systems become more effective at eliminating the drug

Biochemical tolerance - target tissue may show altered sensitivity to the drug

Behavioral tolerance - reduced behavioral response to a drug
What enzymes in the body metabolize alcohol?
1.) Alcohol and aldehyde dehydrogenase
2.) Catalse
3.) Alcohol oxidase (CYP)
What is the 1st step to ethanol elimination?
Alcohol dehydrogenase (zero order, primary route, not inducible)
What is the 2nd step to ethanol elimination?
Acetaldehyde to acetic acid (Aldehyde dehydrogenase)
What are the symptoms of ethanol withdrawal?
-Early signs: (within one day) include vivid dreams, insomnia, tachycardia and hypertension, seizures
-One to two days: convulsions appear and increase in intensity, may be life threatening
-About 3 days: delirium tremens appear

Visual hallucinations may occur anytime after the start of withdrawal
What is delerium tremens?
Shaking frenzy - can include severe tremors, delirium, confusion, hallucinations, agitation, diaphoresis, and sympathetic overdrive leading to cardiovascular instability and death
What are the goals of alcohol withdrawal?
- Prevention and treatment of withdrawal symptoms (including seizures and delirium tremens)
- Long-term abstinence
- Entry into ongoing medical and alcohol-dependence treatment program
How do you treat alcohol withdrawal?
1.) Pharmacotherapy
Benzodiazepines - for uncomplicated withdrawal
Benzodiazepines in the ICU - Alcohol related seizures (complicated withdrawal)

2.) Treating nutritional deficits and electrolyte abnormalities
Vitamin B1 for wernicke-korsakoff syndrome, alcohol hypoglycemia
When do seizure symptoms typically present in alcohol withdrawal?
End of the first day
Untreated delirium tremens mortality rate...
20%
What is aversive therapy in the context of alcohol abuse?
Disulfiram
It inhibits alcohol dehydrogenase, makes user sick when consuming alcohol. Reserved for the motivated abstinent patient that fear relapse
What is disulfiram? When would it be appropriately used?
A drug for aversive therapy to prevent alcohol relapse
It inhibits alcohol dehydrogenase, makes user sick when consuming alcohol. Reserved for the motivated abstinent patient that fear relapse
What is naltrexone?
Competitive mu-opiate receptor antagonist that reduces drug cravings
Appears weak at preventing a lapse, but better at preventing a lapse from becoming a relapse
What is acamprosate?
GABAergic agonist the modulates alcohol cravings
Appears good at preventing a lapse
What are some nutrient-associated deficits that lead to more severe disorders associated with alcohol abuse?
1.) Alcohol amnestic disorder - Korsakoff's psychosis
2.) Alcoholic Encephalopathy - Wernicke's encephalopathy
What is Korsakoff's psychosis?
Aka Alcohol amnestic disorder (thiamine deficiency)
Irreversible short term memory distrubance
May be accompanied by cerebellar signs, peripheral neuropathy, and cirrhosis, rarely occurs before the age of 35
What is Wernicke's Syndrome?
Aka Alcoholic encephalopathy (thiamine deficiency)
Presents as (MOAN) Mental status changes, Ophthalmoplegia, Ataxia, Nystagmus.
May clear in a few days or weeks or progress to Korsakoff's Syndrome.
Responds rapidly to large doses of parenteral thiamine.
What are the characteristics of caffeinism?
Restlessness
Nervousness
Excitement
Insomnia
Diuresis
Flushing
GI upset
Muscle twitching
Irritability
Jitteriness
What is the mechanism of action of caffeine?
Peripheral and Central effects
1.) Peripheral - inhibition of phosphodiesterases results in sustained levels of cAMP and cGMP. Second messengers of smooth muscle relaxation. Mechanism of action for asthma, minimal role in central nervous system

2.) Central - Adenosine antagonism. Adenosine is a natural modifier of neurotransmitter function. Adenosine inhibits neurotransmitter release and postsynaptic processing. GABA-inhibitory action antagonism, via benzodiazipine allosteric site.
Caffeine's pharmacological effects on the body
CNS and Respiratory Stimulant
Cardiac Stimulant
Coronary Vessel Dilatory/Cerebral Vessel Constrictor
Smooth muscle relaxer
Skeletal muscle stimulant
Diuretic
Caffeine's effect in the event of coronary insufficiency.
Reversed actions
Cardiac depressant
Coronary Vessel contrictor
Cannabis Signs and Symptoms of Intoxication
Euphoria and Giddiness
Increased appetite
Depersonalization or delirium
Panic, Paranoia, and hallucinations when large amounts are ingested or in stressful social settings
Cannabis effects
Cardiovascular
Mild increase in heart rate, blood pressure
Increased angina frequency
Increased risk of myocardial infarction
Cardiomyopathy
Arrhythmia
No reflow (peripheral vascular disease)
Strokes
Vasculitis
Is there a dependence associated with Cannabis use?
Acute use shows no signs of dependence

Chronic low-dose users may show cumpulsive drug seeking and drug-use behaviors consistent with addiction
Effects of cannabis in heavy users
Amotivational syndrome of apathy, dullness, impaired judgment, decreased concentration and memory, loss of interest in personal hygiene, and a general reduction of goal-directed behavior
What is a hallucinogen?
A drug that produces a change in sensory perception, generally also thought to change mood and thought patterns
Effects of acute intoxication of a hallucinogen?
Denationalization: Distortion of perception, mood and thought

Higher doses: Delusions and visual hallucinations. Cross-over sensory patterns (hear sights, smell sounds, etc...)

Powerful hallucinatory drugs can trigger flashbacks (LSD), most commonly in recurrent users or those with personality disorders
Treatment strategies for hallucinogens
Limit sensory stimulation
Place the patient in a safe environment
Treat the symptoms as they appear
What is phencyclidine?
aka PCP
Dissociative anesthetic chemically related to ketamine

Often used as a spike for another drug of abuse
Chronic effects from phencyclidine use?
Flashbacks
Persistent Speech Problems (Stuttering, inability to articulate)
Social withdrawal and isolation
Toxic Psychosis
Effects from phencyclidine use
Provides feelings of detachment from environment and self

Violent outbursts may reflect personality (antisocial) more than the drug
Treatments strategies for phencyclidine
Limit sensory stimulation
Place the patient in a safe environment
Treat symptoms as they appear
Effects of acute intoxication from inhalants
Intoxication
Impairment of judgement and sense of reality
Hallucinations
Inhalant use signs
Rash/irritation around mouth and nose
Red, glassy, watery eyes
Excitability and unpredictable behavior
Odor on clothes, skin, and breath
Chronic use outcomes from inhalants
Cardiac arrhythmias
Liver and kidney damage
Cancer
Gateway use to other drugs of abuse
What are the different endogenous opioids? Which receptors do they bind?
Enkephalins - δ receptors
Endorphins - µ receptor
Dynorphins - K receptors
How do you treat opiate withdrawal
Important to stabilize any medical issues
Rarely lifethreatening:
HTN, Racing heart, and loss of electrolytes (vomiting and diarrhea)

If you want to relieve symptoms: Methadone or buprenorphine are recommended

Clonidine can be used to treat the hypersympathetic activity

Buprenorphine-naloxone combinations for maintenance

Aversive therapy - Naltrexone for opiates
What is dextromethorphan?
Opiate normally used for cough suppression. Intoxication achieved by large oral doses
"Robotripping, skitteling, robodosing"
Effects of high dose dextromethorphan
Hyperexcitability, lethargy, ataxia, slurred speech, diaphoresis, hypertension, nystagmus, mydriasis.

Higher doses: Dissociative anesthetic-like sensations
Antidote to dextromethorphan intoxication
Naloxone
What is naloxone?
A drug that counteracts opiate effects. Often used for opiate overdose (heroin especially) as it will counteract the respiratory depression and other effects
Cross-tolerance and cross-dependence is noted among these agents
Depressants (sedatives, hypnotics, antiepileptics)
Describe the tolerance properties of depressants
Develops slowly
Tolerance is incomplete (tolerance to respiratory depression is slow to develop and has a ceiling)
Describe the features of abstinence syndrome for depressants
Potentially life-threatening for patients to experience withdrawal (regardless of half-life)

Timeline for symptom development depends on drug half-life, alcohol is relatively short, benzos are relatively long.
How do you treat withdrawal symptoms from depressants?
Begin a slow taper process to reduce the selected drug. Withdrawal will progress but should be stabilized at mild symptom stage (mild anxiety, insomnia, irritability, and muscle spasms)
What is the abuse pattern in patients with stimulant use?
Rush - intense pleasure as drug is administered
Run - Periods of intense drug use, also called Binge
Crash - The end of a run, characterized by prolonged sleep, depression, hunger and weakness
How do you treat stimulant withdrawal? What are somethings to note/consider?
Monitor for depression/suicide
Monitor CV/heart (EKG, HR, BP)
Patients without suicidal tendencies or depression can be treated outpatient
Cocaine may kindle seizures with repeated use
____________ produces profoundly positive feelings (empathy, relief of anxiety, extreme relaxation) at recreational doses
Ecstasy
_____________, in the presence of alcohol, is metabolized to ____________________, a longer-acting psychoactive compound
Cocaine, Cocaethylene
What is the risk of mixing alcohol and cocaine?
Alcohol induces the transformation of cocaine to cocaethylene, a compound that has a higher risk of death
What are the 2008 Agency for HealthCare Research Guidlines for tobacco use/abuse?
Tobacco dependence is a chronic disease that may require repeated intervention.
Effective treatments exist that can produce long-term abstinence
Every patient that uses tobacco should be offered at least one tobacco dependence treatment option
Must institutionalize the consistent identification, documentation and treatment of all tobacco users
There is a strong relationship between tobacco dependence counseling and cessation therapy success
What is the general approach to substance dependence
Pharmacological treatments are secondary to psychosocial therapy
What are the five stages of change in regards to substance abuse?
1.) Precontemplation - no intent, unaware, unwilling to change
2.) Contemplation - willing to consider changing
3.) Preparation - getting ready to make the change
4.) Action - change has begun
5.) Maintenance - Sustain and strengthens change
6.) Relapse - Expected, bump in the road
Cannabinoid receptors of the brain
CB1 - Only found in the CNS and mediates the rewarding properties of cannabinoids

CB2 - prominent in the immune system
Endogenous hormones that are similar to cannabis
Endocannabinoids - homologs of marijuana produced in the brain -- act as a retrograde messengers and may influence neruotransmitter release from the pre-synaptic neuron

Anandamide -- is an endocannabinoid with many effects. Altered memory formation, appetite stimulation, reduced pain sensitivity, protection from excitotoxic brain damage
Active ingredients of cannabis. What effects do they have on the body?
1.) Δ9-tetrahydrocannabinol (THC): Effects vary -- include relaxation, mood alteration, stimulation, hallucination, paranoia, stimulates appetite and reduces nausea. Sustained use can cause addiction

2.) Cannabidiol: Non-psychoactive cannabinoid. Used for reducing pain and inflammation, and controlling epileptic seizures
Features of cannabinoid hyperemesis syndrome
Current, heavy cannabis use
Abdominal pain, epigastric or periumbilical
Recurrent episodes of severe nausea and intractable vomiting
Compulsive bathing with symptom relief
Resolution of symptoms with cannabis cessation
Failure of standard antiemetics to resolve nausea and vomiting
Mechanism of action of buprenorphine
mu receptor partial agonist
kappa receptor antagonist
Methadone mechanism of action
mu receptor agonist, NMDA antagonist
Fentanyl receptor mechanism of action
mu receptor agonist
weak kappa receptor agonist
Mechanism of action of cocaine
Increases synaptic DA levels by binding to the plasma membrane DA transporter and blocking reuptake of the NT
Mechanism of action of amphetamine
Reverses dopamine transporter
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